Transradial Interventions Difficult Anatomic Substrate: Challenges and Solutions Ramon Quesada, MD, FACP, FACC, FSCAI Medical Director, Structural Heart ,Complex PCI & Cardiac Research Miami Cardiac & Vascular Institute, Miami, Florida Clinical Associate Professor of Medicine, Florida International University Herbert Wertheim School of Medicine

Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement or affiliation with the organization(s) listed below. Affiliation/Financial Relationship Company Grant/Research Support None Consulting Fees/Honoraria Abbott, Cordis, St. Jude, W.L. Gore, Terumo & Boston Scientific Corporation Major Stock Shareholder/Equity None Royalty Income None Ownership/Founder None Intellectual Property Rights None Other Financial Benefit None

TRA~ Start to Finish Subclavian & Coronary Cannulation ACCESS Traversing Subclavian Tortuosity Anatomical Variations Rare but possible Complications ACCESS Anatomical Variations Radial Artery Spasm Perforation Removal of Sheath/ Catheter Radial Artery Occlusion Hematoma / Pseudoaneurysm Bleeding/Compartment syndrome Hemostasis

But ….Does Difficult Anatomy = Difficult Decisions?

Dealing with Difficult Anatomic Substrates using TRA You may not know “pre-access” that an anatomic challenge exists If the patient has a radial pulse then the anatomy distal to the wrist can be managed Getting the “right tool and technique” for the job translates into successful TRA access even with difficult anatomy

Forearm Normal Vascular Anatomy Fujii et al. J Invasive Cardiol 2010;22:536-40

Incidence and Implications of Arterial Anomalies Analysis and incidence of arterial anomalies completed by Fujii et al on 163 consecutive patients. Classification of all anomalies and then stratification of the “difficulty” of transradial access for that anomaly was completed. Overall it was concluded that 98.8% of patients were acceptable for TRA. Fujii et al. J Invasive Cardiol 2010;22:536-40

Dealing with Difficult Anatomic Substrates using TRA You may not know “pre-access” that an anatomic challenge exists If the patient has a radial pulse then the anatomy distal to the wrist can be managed Getting the “right tool and technique” for the job translates into successful TRA access even with difficult anatomy

Anatomical Variations Fujii et al. J Invasive Cardiol 2010;22:536-40

Anatomical Variations Fujii et al. J Invasive Cardiol 2010;22:536-40

Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064 Causes of Transradial Approach Percutaneous Coronary Intervention Failure Radial Artery Loop Guidewire-induced Dissection Severe Spasm not relieved by inter-arterial nitro & verapamil Severe Subclavian Tortuosity Dehghani, P. et al. J Am Coll Cardiol Intv 2009;2:1057-1064

Radial Anomalies and Procedural Failure 7% 2.3% 2.5% 2.0% Lo TS, et. Al. Heart, 2009:95: 410-15

Difficult Anatomic Challenge Scenario #1 “the radial loop”

360o Radial Loop

Wire across 360o Radial Loop

Use a 2.0 Balloon over Wire followed by 6 Fr Diagnostic Catheter

“Possible” Vascular Complications Associated with TRA May Occur with Difficult Anatomy Spasm Bleeding Hematoma Compartment Syndrome Perforation, laceration, dissection Evulsion of artery Pseudo-aneurysm Subcutaneous granulomatous reaction to hydrophilic coating Cutaneous infection Subacute and delayed occlusion Digital ischemia Accelerated atherosclerosis Transient vocal cord paralysis Mediastinal hematoma Delayed reflex sympathetic dystrophy

Dealing with Difficult Anatomic Substrates using TRA You may not know “pre-access” that an anatomic challenge exists If the patient has a radial pulse then the anatomy distal to the wrist can be managed Getting the “right tool and technique” for the job translates into successful TRA access even with difficult anatomy

With difficult anatomy choose the right tool to avoid complications

Adjunctive Tools for TRA For tortuosity at the radial brachial level, and anatomical variations, 0.014 coronary floppy wires are sufficient.

Conventional coronary wire negotiating radial tortuosity

Radial Artery Tortuosity: How to Navigate Feldman 1

Radial Artery Tortuosity: To overcome tortuosity, use conventional Radial Artery Tortuosity: To overcome tortuosity, use conventional .014" standard coronary wire. Feldman 3

Radial Artery Stenosis: To overcome stenosis, use conventional .014" standard coronary wire Poveda

How would you approach this radial?

Use gentle catheter navigation over a universal 0.14” coronary wire 6 Fr radial catheter

Proceed with the case…

How do you deal with tortuousity? How to Optimize TRA ~ Subclavian & Coronary How do you deal with tortuousity? Use a Benson or Wholey wire into the ascending aorta. If there is significant tortuousity in the subclavian artery, switch to a stiff exchange 0.035 or 0.038 Cook or Amplatz wire. Pull the wire into the shaft of the catheter in order to facilitate torquing for coronary cannulation. Quesada et al, “Transradial Coronary Interventions”, Interventional Cardiology Secrets, 2003, pp. 203-210

Subclavian tortuosity/coronary cannulation with wire support

Commonly Used Guiding Catheter Shapes Left Arm Approach Right Arm Approach For Lesions in LCA - XB 3.5 - XB 3.0 - JL 4 - JL 3.5 - Kimny For Lesions in RCA - JR 4 - AL I or AL II - AL I - Castillo 1 & 2 - Barbeau

New Diagnostic Radial Catheters TIG-MOD 4.0 Ikari Right Ikari Left 31

Right transradial access in very anterior arch (bovine) Diagnostic Right transradial access in very anterior arch (bovine) Note: catheter is pointing up resulting in dye induced dissection of left main LAD Castro 10 18 07 dissection lad

Special Featured Catheters TIGER and JACKY Two specific curves that are utilized for right radial approach. Either may be used to facilitate easy cannulation of both the RCA and LCA. The LV can also be entered, pressures measured and hand injection performed. Show each catheter and how the tips are different. Be sure to point out that each is used independently of the other. PERSONAL PREFERENCE 33

Scenario #2 “The Aberrant Artery”

Subclavian Anatomic Challenge The Aberrant Right Subclavian Artery (Arteria Lusoria)

Right Subclavian Angiography This is an Arteria Lusoria A 6-French radial guiding catheter was advanced into the right subclavian artery and appeared to go directly into the descending aorta, despite repeated attempts to access the ascending aorta

How can this be overcome? In an elective case switching to the left radial or femoral can be considered In this case – the patient was a STEMI and DBT was a factor Are there any technical maneuvers that would permit negotiation of this 70° angle?

No…. Attempting to negotiate the angle using the Kimny catheter and stiff wire could cause a dissection and a real MESS! My solution to this challenge was not to switch access but to Switch catheters… I chose an angulated pigtail catheter with a soft Benson wire.

Pre-intervention coronary angiography: note catheter angulation at the entrance of the ascending aorta

Pre-intervention coronary angiography: total occlusion distal RCA (infarct related vessel) TIMI flow = 0 GR4 guiding catheter

Post aspiration thrombectomy Post PCI & BMS

Avoid dissection as a result of cannulating via arteria lusoria Forms an acute angle (70°) with the proximal aortic arch aberrant right subclavian artery the false lumen with retained contrast medium Huang, I, J Chin Med Assoc • July 2009 • Vol 72 • No 7

Conclusions Radial artery anatomical variations and the inherent challenges to interventional technique can be handled with careful selection and use of wires and guide catheters. Awareness of possible complications to be avoided is the most useful risk reduction technique. Slow down and be Sure

Thank You!